Healthcare Provider Details

I. General information

NPI: 1750450474
Provider Name (Legal Business Name): MICHAEL J. MASSONI B.S., C.C.P., L.P
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3612 N FLAMINGO AVE
BETHANY OK
73008-3664
US

IV. Provider business mailing address

3612 N FLAMINGO AVE
BETHANY OK
73008-3664
US

V. Phone/Fax

Practice location:
  • Phone: 405-787-0978
  • Fax: 405-787-2677
Mailing address:
  • Phone: 405-787-0978
  • Fax: 405-787-2677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberLP22
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: